PERSPECTIVE

published: 10 June 2022

doi: 10.3389/fped.2022.899653

Screening for Early Emerging Mental

Experiences (SEE ME): A Model to
Improve Early Detection of Psychosis
in Integrated Primary Care
Kristen A. Woodberry 1,2* , Kelsey A. Johnson 3,4 and Lydia A. Shrier 4,5
1
Center for Psychiatric Research, MaineHealth, Portland, ME, United States, 2 Department of Psychiatry, Tufts School
of Medicine, Boston, MA, United States, 3 Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, MA,
United States, 4 Division of Adolescent and Young Adult Medicine, Boston Children’s Hospital, Boston, MA, United States,
5
Department of Pediatrics, Harvard Medical School, Boston, MA, United States

Early intervention in serious mental health conditions relies on the accurate identification
of adolescents and young adults at high risk or with very recent onset of psychosis.
Current early detection strategies have had limited success, identifying only a fraction of
these individuals within the recommended 3- to 6-month window. Broader public health
Edited by:
Soumitra Das,
strategies such as population screening are hampered by low base rates and poor
NorthWestern Mental Health, Australia self-report screen specificity. Screening for Early Emerging Mental Experiences (SEE
Reviewed by: ME) is a three-stage “SCREEN—TRIAGE—ENGAGE” model for the early detection of
Shivanand Kattimani,
psychosis in integrated primary care adolescent and young adult patients during the
Jawaharlal Institute of Postgraduate
Medical Education and Research period of peak onset. It builds on the KNOW THE SIGNS—FIND THE WORDS—MAKE
(JIPMER), India THE CONNECTION framework outlined on psychosisscreening.org and developed with
Sharad Philip,
The Leprosy Mission Trust India, India
input from community collaborators. Systematic screening aims to expand the reach
*Correspondence:
of early detection and reduce reliance on provider knowledge. Triage and engagement
Kristen A. Woodberry by trained mental health clinicians aims to improve the specificity of screen responses,
Kristen.Woodberry@mainehealth.org
enhance engagement in appropriate care, and reduce provider burden. Leveraging the
Specialty section: low stigma of primary care, its reach to non-help-seeking adolescents and young adults,
This article was submitted to and the mental health training of clinicians within integrated care practices, SEE ME has
Child and Adolescent Psychiatry,
potential to improve the benefit/risk ratio of early detection of psychosis by improving
a section of the journal
Frontiers in Pediatrics both the sensitivity and specificity of screening and clinical response. We review the
Received: 18 March 2022 rationale and design of this promising model.
Accepted: 13 May 2022
Published: 10 June 2022 Keywords: first episode psychosis (FEP), early intervention (EI), prodrome, serious mental illness (SMI),
adolescents
Citation:
Woodberry KA, Johnson KA and
Shrier LA (2022) Screening for Early
Emerging Mental Experiences (SEE
INTRODUCTION
ME): A Model to Improve Early
Detection of Psychosis in Integrated
Psychotic symptoms are widely considered a marker of the most serious mental health conditions,
Primary Care. and predictive of more severe outcomes (1, 2). The first three-to-six months after onset of acute
Front. Pediatr. 10:899653. psychosis is a critical window for early intervention in these conditions (1, 3–5). It is the best
doi: 10.3389/fped.2022.899653 opportunity to improve outcomes for affected youth and mitigate the elevated risks for suicide,

Frontiers in Pediatrics | www.frontiersin.org 1 June 2022 | Volume 10 | Article 899653

Woodberry et al. Psychosis Screening in Primary Care

hospitalization, and violence that peak with the emergence of SEE ME MODEL
acute psychosis (6–8). A longer duration of untreated psychosis
(DUP) is robustly associated with greater symptom severity Overview
and functional impairment, even long-term (3, 4, 9). Most The authors propose the SEE ME model based on extensive
individuals do not receive appropriate care until well beyond this discussions with New England primary care, psychosis
window (5, 9). specialty care, and community stakeholders. Its three stages, or
Factors contributing to DUP have been identified primarily components, were conceptualized to improve reach (sensitivity)
through retrospective interviews with individuals once they have and timeliness of early detection of serious mental health
received coordinated specialty care (CSC, current best practice conditions in a manner that minimizes psychosis-specific
for psychosis). A prominent conceptualization views these treatment/labeling exposure for non-psychotic or subthreshold
factors within a “supply and demand” framework (10). “Supply” experiences (improved specificity). Importantly, it was designed
factors are those that influence referral pathways and access to with the aspirational goal of averting crises, hospitalizations,
treatment. They include aversive experiences with the mental suicide attempts, violence, or police involvement commonly
health system, provider misattribution, and racial disparities experienced by current youth. For this and other practical
(11, 12). “Demand” factors are those that influence help- reasons (see section “Focus on Primary Care”), it was designed
seeking or treatment engagement. These include concerns about for United States primary healthcare clinics that serve the general
stigma, overvaluing of self-sufficiency, lack of social support, community and have the integrated mental health capacity to
and misattribution of symptoms (10, 11). Access to specialty conduct the 3 component activities: screen, triage, and engage.
psychosis treatment, usually via hospitalization, often involves The underlying assumption of SEE ME is that individuals
coercion and other aversive experiences, such as restraint, suffering with psychosis are not “seen” in time. There are
that impede treatment engagement and future help-seeking too few healthcare contacts that explicitly invite disclosure
(13, 14). Strategies that foster decisional autonomy or shared and explore private experiences of altered reality in a non-
decision-making must become more efficient to simultaneously stigmatizing manner. When community primary and mental
reduce DUP and effectively engage individuals in a pathway to healthcare providers do recognize psychosis, many are unsure
recovery (9, 14, 15). how to respond or connect individuals with timely care (24,
New efforts must extend beyond the current reliance on 25). Figure 1 illustrates two pathways to care for a hypothetical
community education and treatment of help-seeking individuals individual presenting to primary care with insomnia, an early,
(2, 5). Screening is a logical next step but common mental but non-specific, symptom commonly experienced in psychotic
health screens, used only sporadically, do not include items disorders. Usual care (top) too often involves elongated and
probing psychosis. It is impractical to conduct widespread often aversive pathways from psychosis onset to appropriate
specialized interviews, yet none of the internationally-developed care. SEE ME (bottom) is designed to facilitate a shorter, direct,
self-report psychosis screening tools (see section “Screening and gentler path.
Tool Options”) are sufficiently accurate in general population,
particularly adolescent, samples (16, 17). Screens for less Focus on Primary Care
common conditions such as schizophrenia generally identify SEE ME’s focus on primary care settings is based on four factors.
too many “false positives” (18). Screening for psychosis poses First, primary care is the natural home for early intervention
additional challenges. Psychotic-spectrum experiences (e.g., in potentially chronic conditions; providers are trained to
hearing a voice when no one is present, suspiciousness), are recognize clinical syndromes. Second, primary care settings carry
simultaneously more common and less predictive of later low stigma, particularly for individuals and families who do
psychotic disorder in children and adolescents relative to adults not identify as having mental health concerns or are reticent
(19, 20). Abstract and highly subjective psychosis probes are to seek mental healthcare (25). Third, primary care settings
easily misunderstood by individuals with low cognitive and typically see individuals through adolescence into adulthood,
language capacities, but this misunderstanding is only identified individuals not in school, and individuals who initially present
through interview queries (21). Finally, some psychosis screen with physical health concerns such as insomnia, inattention,
items, e.g., those probing supernatural experiences, suspicion, or unexplained concerns about body integrity or functioning.
or paranoia, may be “falsely” endorsed by individuals with Fourth, by following patients over time, primary care providers
certain religious beliefs (e.g., ability to hear God’s voice) have a unique opportunity to note change and develop a
or exposure to crime or discrimination (i.e., justified fears relationship that invites disclosure of mental health concerns.
or suspiciousness). Misattribution of these endorsements to
psychosis can exacerbate existing health disparities (16, 22,
23). Screening by itself may not have a positive benefit- STAGE SPECIFICS
risk ratio (2). Early detection strategies are needed that
identify many more youth within the critical window for Figure 2 illustrates the three stages of the SEE ME
intervention, helping them stave off aversive interactions with model (screening, triage, and engagement), and their
mental health and other systems in response to crises, while linkage to the KNOW THE SIGNS, FIND THE WORDS,
simultaneously minimizing risks to individuals at low risk for and MAKE THE CONNECTION materials available at
psychosis. www.psychosisscreening.org (26). These online materials

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Woodberry et al. Psychosis Screening in Primary Care

FIGURE 1 | Targeted impact of SEE ME on pathways to care. Since SEE ME seeks to identify acute psychosis as well as high psychosis risk, the time from
psychosis onset to specialty care represents the Duration of Untreated Psychosis (DUP) for individuals with psychotic disorders and Duration of Untreated Illness
(DUI) for individuals identified during an at risk state. Those at risk who transition to a psychotic disorder would have a subsequent DUP.

were developed through iterative discussions with community for eliciting psychotic-spectrum experiences, be easily scored,
stakeholders to support indicated screening: provider recognition and have thresholds and/or norms for diverse populations
of warning signs, inquiry about psychosis, and connection with (and considerations for relevant sociodemographic factors and
services. However, anecdotal evidence from provider training specific selected or indicated subpopulations). Tools do exist
and widespread resource distribution in Massachusetts suggested and are used in primary care (e.g., Prodromal Questionnaire
that education and resources alone had minimal impact on Brief, PQ-B), but no single tool meets all of these criteria.
improving early detection. Similar to other successful early The reader is referred to available analyses and guidelines to
intervention protocols (e.g., Screening, Brief Intervention, and select the best screen for their context (2, 28–30). The SEE
Referral to Treatment, SBIRT) (27), SEE ME proposes systematic ME model is designed to accommodate current tools and
screening, i.e., asking all or a subset of patients a minimum set their limitations through skilled mental health triage of all
of questions about psychotic-spectrum experiences, ideally via “positive” screens.
self-report. Leveraging the integrated care structure, the bulk of
“SCREEN-TRIAGE-ENGAGE” activities are borne by integrated Universal vs. Selective vs. Indicated Options
clinicians with mental health expertise. Medical providers can The long-term goal is universal screening: screening all, e.g.,
play a role in recognizing mental health concerns, including adolescent and young adult, primary care patients for psychosis.
potential psychosis, and connecting patients to mental health Broad implementation awaits a brief general mental health
services, but do not carry the primary burden for this. Triage screening tool that includes items related to psychosis. Selective
and engagement of positive screens, conducted by a mental screening, screening subpopulations with above-average risk
health clinician across one or more visits or collateral contacts, (e.g., patients with identified mental health concerns or a
should improve outcomes and mitigate risks for both “true” and positive family history of psychosis) may be most realistic in the
“false” positives. short term, particularly if conducted entirely by mental health
We outline the core components and options that may vary clinicians. Indicated screening entails screening or assessment of
with funding and practice characteristics. individuals on the basis of symptom or behavioral indicators.
This most common strategy relies on both observable indicators
Screening and savvy providers. Strategies may also be combined, for
Screening Tool Options instance, mental health clinicians conducting selective screening
Systematic screening depends on the availability of a very of all referred patients within a set age range and physicians in
brief self-report measure written at no more than a 5th grade the same practice conducting their own indicated screening of
reading level (2). (Ideally, caregiver and interview versions would patients when they recognize an early warning sign (e.g., new
also be available.) The tool should have established validity difficulty reading or following a conversation).

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Woodberry et al. Psychosis Screening in Primary Care

FIGURE 2 | SEE ME model.

Protocol Considerations assessment or return to sensitive or vague subjects once a trusting

Success of any screening effort relies on efficient workflows, relationship is established.
technical aids and staffing, and clear guidelines for administering, Maintaining curiosity and closeness to the patient’s experience
documenting, tracking, and responding to screens. Electronic and language are essential to understanding the nature of
health record access and entry is ideal for providers, whereas these experiences within a broad psychosocial and mental
accessibility and privacy are priorities for patients. Protocols health context. Clinicians must have sufficient diagnostic skills
must protect adolescent privacy to assure accurate report of and access to medical, developmental, psychiatric, and other
potentially sensitive experiences whether via paper, tablet, or specialty consultations to consider alternative diagnoses and
online. Simultaneously, screen results and triage decisions must comorbidities (e.g., Trauma-related Disorders, Anxiety and
be documented to prompt appropriate next steps and allow for Obsessive Compulsive Disorders, Developmental Disorders). For
monitoring over time. complex and atypical presentations, referral for comprehensive
medical-mental health evaluations is recommended.
Triage The first assessment task following a positive screen or
The mental health clinician’s primary task is to follow-up indicated referral is to determine whether there is psychotic
on positive psychosis screens and any reported or observed content and/or whether experiences or indicators are best
indicators to determine the appropriate next step. The assessment explained by cultural, developmental, psychosocial, or other
must be brief. These integrated mental health clinicians do mental health factors. As illustrated within Figure 2, patients
not typically have the time or training to conduct structured without specific psychosis concerns are triaged to appropriate
diagnostic interviews to differentiate attenuated and acute mental health or social services (ENGAGE: PATH 1.). For
psychosis from other concerns. For young people who have patients with psychotic-spectrum experiences, there is a second
difficulty sharing their experiences, clinicians may extend their task: to assess whether patients’ experiences rise to the threshold

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Woodberry et al. Psychosis Screening in Primary Care

warranting a specialized psychosis assessment (if no, PATH 2; and family member together can create a shared understanding,
if yes, PATH 3). Clinicians assess for impact, persistence, and elicit and address misunderstandings and mistaken assumptions,
progression of psychotic-spectrum experiences, corresponding to and foster normalizing language to reduce stigma. Individual
established criteria for psychosis risk and disorder (31). time can be provided to address sensitive questions, but SEE ME
Clinicians must also assess and respond to potential imminent advocates for joint engagement when possible. Family support
risk for harm to self or other (if yes, PATH 4). This should (e.g., National Alliance on Mental Illness, NAMI) can have a
follow good clinical practice, with clinicians adhering to agency major impact on the young person’s engagement and wellbeing.
procedures and relevant laws. It is critical that clinicians avoid
assuming that psychotic symptoms are by definition dangerous. Engagement Through Messaging and Clinic and
Risk must be taken seriously, but some patients can live safely Community Cultures
with even violent command hallucinations. Fostering a practice and community culture that challenges
stigma, expects recovery, and normalizes a continuum of
Engagement mental wellness may improve mental health literacy and more
Critical Aspects of Engagement rapid access to quality care. This can occur through waiting
Integrated mental health services provide an opportunity to help room, website and other public messaging, visit protocols, and
patients find the language to share their private experiences provider trainings.
with caring professionals and embark on pathways toward
meaningful lives. Engagement is its own stage in the SEE- Collaboration and Training
ME model to maximize the likelihood they are successful. Although SEE ME provides a model, eliciting practice-level
In addition to general good practice (e.g., understanding and expertise, ideas, and concerns is needed to create efficient
respecting patients’ values and goals), components of engagement and effective screening workflows and provider engagement.
specific to psychosis include (1) providing psychoeducation Identifying and supporting practice champions and offering
to help patients envision and begin to own their recovery, flexibility is key. A commitment to systematic screening
(2) explicitly countering common psychosis-related myths implicitly communicates that psychotic-spectrum concerns are
and stereotypes (e.g., that these experiences are the person’s not uncommon, are more easily managed when shared than
fault, untreatable, or imply inevitable violence, disability, or when kept secret, and that someone is interested in hearing
inhumanity) and, (3) helping them establish a safe connection about them. Repeated screening (e.g., annually) may facilitate
with appropriate psychosis-relevant care. Engagement may more rapid disclosure or engagement even for initially reluctant
consist of a brief discussion, introduction, and warm handoff youth or families.
to a program clinician, a gradual relationship-building, targeted Practice-level trainings should include the voices of lived
psychoeducation and family meetings, shared viewing of online experience and review of patients not “seen early enough”
videos and testimonials (e.g., https://strong365.org), handouts to help with provider buy-in. Spreading trainings over time
or books, or introduction to a peer support partner or group facilitates integration and sustained vigilance. Trainings targeting
in recovery. With particularly disengaged youth or families, medical providers must improve awareness of warning signs,
every effort must be made to “leave the door open” and avoid strengthen provider comfort discussing psychosis, emphasize a
aversive interactions. low threshold for referral to integrated mental health clinicians,
For the roughly 5–15% of young people with subthreshold and address common medical and case management challenges.
(e.g., non-distressing or infrequent) psychotic-like experiences Trainings for the integrated mental health clinicians cover
(20), clinicians “Educate and Monitor” and/or rescreen at regular epidemiology and conceptual aspects of psychosis onset to shape
intervals (e.g., every 3–12 months; PATH 2). This education realistic expectations and capacity for psychoeducation. Role
focuses on the importance of good mental hygiene and of seeking plays are used to establish competency in specific “SCREEN-
help if experiences progress. Thoughtful safety discussions TRIAGE-ENGAGE” skills. Practice managers and others who
can be protective beyond physical safety if they address may play a role in administering or tracking self-report
internalized stigma, prompt important environmental changes, screens are trained on the workflow, tone and wording for
and open up productive and compassionate communication with introducing screens to patients, and strategies to enhance
natural supports. privacy, respond to patient and family questions, and coordinate
subsequent referrals.
Engaging Families and Other Natural Supports
Families and caregivers are often the ones to seek help on Skills Training
behalf of their loved ones. Even those who may minimize Although some primary care and mental health providers are
or dismiss concern about their loved one’s mental health will highly skilled in interviewing adolescents and young adults about
often support efforts to foster success with school, work, or mental health concerns, few are skilled in interviewing patients
financial independence. Adolescent and young adults should about psychosis. Skills must be taught and practiced before a
be supported in directly sharing their experience with these clinician can be expected to employ them. Skills in talking about
significant others whenever possible to keep the focus on psychosis center on creating a shared sense of curiosity and goal
their perspectives and language and to facilitate effective for well-being. Medical and mental health clinicians need skills
communication. Psychoeducation provided to a young person for eliciting and responding to disclosures of psychotic-spectrum

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Woodberry et al. Psychosis Screening in Primary Care

experiences, for differentiating psychotic from non-psychotic SEE ME skills will be important for refinement of training and
content, clinical from non-clinical experiences, integrating first supervision by specialists in psychosis assessment and treatment.
person and collateral reports, and on when to seek consultation
with specialty services. Clinicians also need skills for motivating Impact on Early Detection and
or facilitating youth and family curiosity, hope, and engagement Intervention Outcomes
in appropriate care. The following measures for SEE ME practices over time and
Regular supervision by psychosis experts, either ad hoc or relative to non-SEE ME practices and other agencies are
on a monthly basis, is essential to help frontline clinicians ask suggested to establish impact:
pivotal triage questions (e.g., to differentiate social anxiety from
paranoia or hallucination from traumatic reliving). Supervision 1) Number and percent of referrals to local Coordinated
can be an essential forum for learning how to engage a diverse Specialty Care (CSC) programs.
spectrum of young people and family members, particularly those 2) Degree to which CSC referrals reflect the community’s
who are actively psychotic, have low mental health literacy, have sociodemographic mix.
negative perceptions of mental health services, and face multiple 3) Rates of attendance in CSC intake appointments and
or intersectional barriers in accessing specialty care services. subsequent CSC treatment components.
Every effort must be made to avoid aversive interactions. Finally, 4) Rates of emergency department visits, hospitalizations,
clinicians must learn and practice skills for honoring family suicide attempts, violent incidents, and police encounters
values, addressing stigma, and collaborating in the management prior to and during CSC program participation.
of safety risks. 5) DUP and Duration of Untreated Illness (DUI, measured
from onset of prodromal symptoms) for different offsets:
first psychosis diagnosis, first psychosis- or psychosis-risk-
informed therapy, first antipsychotic, and CSC.
NEXT STEPS FOR TESTING THIS MODEL 6) Short- and long-term clinical and functional outcomes.
Feasibility Well-controlled randomized trials, clustering at the level of
Given challenges implementing even well-established mental practice or patient, will be needed to separate out the impact of
health screens and universal screening protocols such as SEE ME from other initiatives with potential impact on results.
Screening, Behavioral Intervention, and Referral to Treatment
(SBIRT), assessment of feasibility is an essential first step.
We need evidence that integrated care practices will DISCUSSION
provide the necessary time and infrastructure for training
In spite of advances in early detection and intervention in
and implementation. Data are needed on screen response
serious mental health disorders, most affected individuals, if they
patterns, particularly rates of distress due to psychotic-spectrum
receive appropriate care, receive it well outside of the window
experiences, for diverse primary care setting populations
for best outcomes. SEE ME aims to reduce DUP across broader
(pediatric, family medicine, and adult medicine) (30).
segments of the United States population with a 3-stage psychosis
A feasibility study is needed to provide estimates of time,
screening, triage, and engagement model situated within primary
training, and cost for implementation, and the system supports
care. Leveraging the low stigma environment of this setting,
(e.g., electronic health record tools) needed to assure scalability.
it holds particular promise for reaching individuals who are
Finally, it will be important to estimate the degree to which
not seeking mental healthcare or help for psychotic-spectrum
screening identifies young people whose psychotic experiences
concerns. It relies on mental health clinicians integrated within
are not already known, triage rules out individuals whose positive
primary care teams to conduct all three stages, leveraging
screens are unrelated to psychosis, and individuals with threshold
well-placed mental health expertise and minimizing added
level symptoms (and their families) can be effectively engaged
burden on physicians.
in specialty care.
The innovation of this model includes its potential for
identifying psychosis and high risk syndromes prior to the
Screening and Triage Accuracy: Will SEE mental health crises that typically trigger referral to specialized
ME Identify the Right Individuals? care and to reach currently underserved populations. Systematic
In addition to feasibility, success of the model depends on the inquiry into psychotic-spectrum symptoms implicitly educates
accuracy of the screening tools and clinician triage benchmarked young patients that psychotic-spectrum experiences are not
against structured interview assessment of psychosis risk rare and that primary care providers are interested in hearing
syndromes and psychotic disorder, including future psychotic about these experiences. Careful triage and engagement can
disorder. As discussed in section “Screening,” screening improve early detection of subthreshold symptoms that progress
“accuracy” will differ according to the screen and threshold used to threshold symptoms over time, improve the quality of
and the ages, clinical needs, and sociodemographic characteristics care for non-psychotic mental health concerns, and directly
of the population screened. Accuracy of triage across different address internalized stigma within mental health sessions and
levels of prior training and experience as well as demonstrated psychoeducation (32).

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Woodberry et al. Psychosis Screening in Primary Care

Next steps for testing this model include establishing its and edited the manuscript. LS made substantive contributions
feasibility, the capacity for clinical triage to improve on the to the development of the SEE ME model and edited the
accuracy of screening alone, and the model’s efficacy in reducing manuscript. All authors contributed to the article and approved
the duration of untreated psychosis and adverse events, and the submitted version.
engaging currently underserved young people and families in
state-of-the-art care. The long term vision is that no young person
experiences psychotic-spectrum experiences without someone FUNDING
inviting them to share these experiences and receive help.
Funding for the development of the SEE ME model and
preparation of this manuscript was provided by the Sidney
DATA AVAILABILITY STATEMENT R. Baer, Jr. Foundation (KW and KJ), the Massachusetts
Department of Mental Health, Maine Medical Center Research
The original contributions presented in this study are included Institute and Maine Behavioral Healthcare (start-up funding
in the article/supplementary material, further inquiries can be to KW including support to KJ and LS), and NIH (K23
directed to the corresponding author. MH102358 to KW).

AUTHOR CONTRIBUTIONS ACKNOWLEDGMENTS

KW initiated and led the conceptualization of the SEE ME model We are grateful to Judi Siegel, John Straus, and Eugene D’Angelo
and wrote the initial draft. KJ made substantive contributions for providing particularly valuable advice and support for
to the development of the SEE ME model, created the figures, screening in primary care settings.

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30. Johnson KA, Shrier LA, Eiduson R, Parsa N, Lilly M, D’Angelo E, et al. original author(s) and the copyright owner(s) are credited and that the original
Depressive symptom screening and endorsement of psychosis risk-related publication in this journal is cited, in accordance with accepted academic practice. No
experiences in a diverse adolescent and young adult outpatient clinic in use, distribution or reproduction is permitted which does not comply with these terms.

Frontiers in Pediatrics | www.frontiersin.org 8 June 2022 | Volume 10 | Article 899653